10 www.pagd.org Q dentistry issues I went through a long phase in my career when I believed a different rotary file was the answer to any of the endodontic problems I had; or maybe it was a rotary technique I hadn’t thought of or hadn’t mastered. I attended almost every new rotary product lecture in search of a better way to find successful results in the least amount of time. We have all become product-dependent to compensate for our insufficiencies. Sealer should not make up for my failure to instrument to the apex. Not long ago in my practice I believed that it was resin sealer and not love that could “cover over a multitude of sins.”1 Resin sealer will only give you a false sense of success and perhaps prevent others from seeing your insufficiencies. And now we have bioactive sealer! That’s like resin sealer with a Superman cape! EDTA is another product we use in endodontics to compensate for our shortcomings. As we plow debris into the apical third with our rotary instruments, we hope that the compaction can be overcome by a stronger concentration of product, and if it doesn’t work, we attest to the patient that the tip of the root must be calcified. Despite the lack of evidence that a higher times and concentrations of EDTA is unnecessary2,3,4 and that calcification happens from the crown down5,6 our ignorance is of the mistake in our technique, not the product. My point is not a material choice issue but rather a herald to maintain a tighter reign on our methods in approaching the apical third. After more than 20 years of doing endodontics in my general practice, some products and techniques have improved my success, but a few principles that guide me now are a bigger determinant of successful outcomes than anything. Any dentist who does endodontic therapy in their practice loves to show their colleagues the beautiful results of their wonderfully-discovered MB2 canal of an upper first molar. Although a missed fourth or even fifth canal is truly a concern for everyone involved, the largest group of failures involves the apical third of the root system.8,9,10,11 According to Siqueira et al, “In most cases, failure of endodontic treatment is a result of microorganisms persisting in the apical portion of the root canal system, even in well- treated teeth.”12 So, to improve our success rates, let’s make some rules about the apical third*: Don’t enlarge the diameter of the apical foramen beyond its original size. Start by determining what the foramen diameter is. In the same way most determine the original working length, you can also notate the original foramen diameter by bringing successively larger K-files until the apex locator registers that the file has exited the tooth. Modern apex locators are accurate in determining the working length only AFTER exiting the tooth and then retracting to the ideal apical constriction7; this is point of achieving patency and in conjunction with determining the maximum apical diameter, is the only time you need to exit the apex. As you increase the K-file size, when you encounter a file that cannot get out of the tooth, then you have the foramen (apical constriction) diameter. Assume that the previous file diameter is the apical diameter, not the file that cannot go through it. After determining the foramen diameter, in my opinion you should no longer exit the tooth. Other schools of thought suggest that you should continue to recapitulate after each successive rotary file, therefore “maintaining” patency throughout the procedure. Achieving patency and maintaining patency are two different things. Researchers and clinicians debate whether maintaining patency throughout the procedure By Levi Evalt, DDS Endodontics— The Apical Third
RkJQdWJsaXNoZXIy MTY1NDIzOQ==